BACKGROUND:Pancreatic cystic masses are increasingly recognized, frequently in asymptomatic patients. Endoscopic ultrasound (EUS) +/- fine-needle aspiration (FNA) is often performed to help differentiate benign cystic masses from those with malignant potential. Given the lack of guidelines, we studied whether surgeons utilize EUS +/- FNA in their decision-making regarding resection.
METHODS: Clinical and imaging data from 10 patients undergoing evaluation and treatment were summarized in a standardized format including age, sex, past medical/surgical history, and symptoms. History included ETOH use and prior pancreatitis. CT and EUS images of the lesion and FNA results were sequentially presented to 8 GI surgeons at a tertiary care center in the following manner: 1. History and physical (H&P), laboratory studies, and CT scan. 2. EUS results. 3. FNA results (cytology, CEA, amylase, lipase). The surgeon was asked specifically whether surgical intervention was indicated before the next data was revealed. RESULTS: A total of 80 presentations were evaluated. 32 of the 80 cases were benign cystic masses and 48 of the 80 cases were cystic neoplasms with malignant potential. Surgery was recommended for 51.3% of all patients based on H&P+CT alone; this increased to 76.3% with the addition of EUS findings. EUS/FNA further increased the proportion for which surgery was recommended to 86.3%. For benign cystic masses, surgery was recommended in 46.9% with CT, increasing to 68.8% following EUS, and 81.3% following FNA. For cystic masses with malignant potential, surgery was recommended in 54.2% with CT, increasing to 81.3% following EUS, and 89.6% with FNA. Only once did the EUS results reverse the decision to operate; FNA never reversed this decision. Other factors, including the presence of symptoms and lesion size inconsistently play a role in decision making. CONCLUSIONS: There is a lack of a systematic approach to pancreatic cystic masses leading to great variation in current practice. In this single center evaluation, EUS and to a lesser extent FNA, appear to increase the decision to proceed with surgery for both benign cysts and those with malignant potential. Given the lack of clarity of the role of EUS +/- FNA in defining surgical decision making in treating pancreatic cystic masses, additional studies and collaborative efforts between surgeons and endosonographers to assess the role of EUS +/- FNA for these patients are needed.
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